Provider Demographics
NPI:1417935008
Name:MOORE, TIMOTHY DEAN (OD, PC)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:DEAN
Last Name:MOORE
Suffix:
Gender:M
Credentials:OD, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 237
Mailing Address - Street 2:109 W. MAIN ST.
Mailing Address - City:STROUD
Mailing Address - State:OK
Mailing Address - Zip Code:74079-0237
Mailing Address - Country:US
Mailing Address - Phone:918-968-3422
Mailing Address - Fax:918-968-4829
Practice Address - Street 1:109 W MAIN ST
Practice Address - Street 2:
Practice Address - City:STROUD
Practice Address - State:OK
Practice Address - Zip Code:74079-3607
Practice Address - Country:US
Practice Address - Phone:918-968-3422
Practice Address - Fax:918-968-4829
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK897152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKT 40577Medicare UPIN